F. Rushton presentation given at the 2012 South Carolina Home Visiting Summit

1. Home Visiting
The Pediatrician’s Viewpoint
Francis E. Rushton, M.D.
frushton@aap.net

2. Hawaii

3. Young Children Not Succeeding in School
(Characteristics of Ages 0 – 3, Subsequently Retained or BB on PACT)
(%) Not (%) of 1995-96
Succeeding
High Risk Group Birth Cohort
53% Abused, Neglected, or in Fostercare 3%
52% Very Low Birthweight (under 1500 grams) 1.4%
48% Lower Educated Mother (under 12 grades) 25%
45% TANF 17%
43% LBW (1500 - 2000 grams) 1.8%
43% Teen Mother (under 18) 8%
42% Food Stamps 32%
37% Mother (age 18 - 20) 17%
36% LBW (2000 - 2500 grams) 6%
Low Risk Group
16% Higher Educated Mother (more than HS) 34%
Source: ORS Data Warehouse files from DHEC Vital Records and DSS linked to SDE PACT data.

4. The Role of Preschool Home-Visiting
Programs in Improving Children’s
Developmental and Health Outcomes
Child health and developmental outcomes depend to a large extent on the capabilities
of families to provide a nurturing, safe environment for their infants and
young children. Unfortunately, many families have insufficient knowledge about
parenting skills and an inadequate support system of friends, extended family, or
professionals to help with or advise them regarding child rearing. Home-visiting
programs offer a mechanism for ensuring that at-risk families have social support,
linkage with public and private community services, and ongoing health,
developmental, and safety education. When these services are part of a system of
high-quality well-child care linked or integrated with the pediatric medical home,
they have the potential to mitigate health and developmental outcome disparities.
This statement reviews the history of home visiting in the United States and
reaffirms the support of the American Academy of Pediatrics for home-based
parenting education and support. Pediatrics 2009;123:598–603

5. Do we know if Home Visiting is
effective?:
• Unfortunately, many of the early programs,
including Hawaii Health Start, have had difficulty
documenting efficacy when taken to scale.
• Not all home visiting programs are alike
• Programs that show greater adherence to
standards are more likely to be effective
• Programs staffed with nursing professionals more
likely to be successful.
• ??Successful program build on the development
of a trusting relationship between the home
visitor and parents over time.

6. Benefits of Home Visiting
• Improve parenting skills • Detect post partum
and the quality of the depression
home environment • Positive impact on
• Ameliorate several child maternal child
behavioral problems attachment
• Improve intellectual • Enhance social supports
development, especially for mothers
with low birth weight • Improve breastfeeding
• Enhance maternal life rates
course

7. Some characteristics of successful
home visiting
• Focused on socially deprived mothers
• Professional or nurse trained home visitor
• Focused on low birth weight or premature
babies
• Provide services of long duration and great
intensity
• Focused on families with many risk factors

8. Linking home visiting to the pediatric
medical home
• Because of increasing complexity of pediatric
morbidity, movement towards team based care
• Home visitors could be critical members of these
teams and augment pediatric medical home
• Partner ships with pediatricians working in the
home setting to provide essential education and
supportive services to at-risk children and
families
• Improving adherence to medical preventive and
treatment regimens

9. Home Visiting Affordable Care Act
• Early Head Start (EHS) – Home Visiting Option
• Family Check-Up (FCU)
• Healthy Families America (HFA)
• Healthy Steps (HS) for Young Children
• Home Instruction Program for Preschool Youngsters
(HIPPY)
• Nurse-Family Partnership (NFP)
• Parents as Teachers (PAT)
• Early Intervention Program for Adolescent Mothers
(EIP)
• Child FIRST

10. Nurse-Family Partnership (NFP)
Nurse-Family Partnership (NFP) targets first-time, low-income mothers
and their children. Mothers must be enrolled in services by the 28th
week of pregnancy, and services conclude when the child turns two
years of age. Home visits provided by nurses seek to promote maternal
and child health, children’s development, and parental economic self-
sufficiency.
For more information:
Nurse-Family Partnership National Service Office
1900 Grant Street, Suite 400
Denver, CO 80203
Phone: 866-864-5226
Fax: 303-327-4260
E-mail: info@nursefamilypartnership.org
Website: http://www.nursefamilypartnership.org

11. Parents as Teachers (PAT)
Parents as Teachers (PAT) targets families from pregnancy to kindergarten entry of children. The
program seeks to promote child development knowledge and to improve parenting practices of
caregivers. The PAT model consists of four components: (1) one-on-one home visits, (2) group meetings,
(3) developmental screenings for children, and (4) a resource network for families. Home visiting
services can range in intensity, from weekly to monthly, as well as in duration.
For more information:
Parents as Teachers National Center, Inc.
Attn: Public Information Specialist
2228 Ball Drive
St. Louis, Mo. 63146
Telephone: 314-432-4330
Toll-free telephone: 1-866-728-4968
Fax: 314-432-8963
Website: www.parentsasteachers.org

12. Early Head Start (EHS) – Home Visiting
Option
Early Head Start (EHS) is a child and family development program that targets low-income pregnant
women and families with children ages birth to three years. EHS provides high-quality, flexible, and
culturally competent child development and parent support services with an emphasis on the role of
the parent as the child’s first and most important relationship. The goals of EHS are to promote healthy
prenatal outcomes for pregnant women, to enhance the development of very young children, and to
promote healthy family functioning. The Home Visiting Option offers and supports comprehensive
services to children and their families through weekly home visits and group socialization experiences.
The key focus of the Early Head Start Home Base program option includes: Health & Safety, Mental
Health, Nutrition, Education, Special Education, Parent Involvement, and Social Services.
For more information:
Administration for Children and Families
Office of Head Start (OHS)
8th Floor Portal Building
Washington, DC 20024
Website: http://www.acf.hhs.gov/programs/ohs/

13. Healthy Steps (HS) for Young Children
For more information:
Healthy Steps (HS) targets parents
with children from birth to 3 Margot Kaplan-Sanoff
Healthy Steps National Director
years. Services are implemented by Vose Hall #419
any pediatric or family health Boston University School of Medicine
medicine practice. Healthy Steps 72 East Concord Street
Boston, MA 02118
focuses on building a close Telephone: 617-414-4767
relationship between health care Email: sanoff@bu.edu
professionals and parents for the Website: http://www.healthysteps.org
promotion of physical, emotional, and The Children's Center of Carolina Health Centers, Inc.
intellectual growth and development 113 Liner Drive
Greenwood, SC 29646
of infants and children. Through Phone: (864) 941-8105
regular home visits and contact with Darlene Hood-Johnson
a health professional, the program Healthy Steps Specialist
864-330-8236
seeks to promote child development, dhoodjohnson@greenwoodchildren.org
promote school readiness, and Sally Baggett
improve positive parenting practices. sbaggett@greenwoodchildren.org
(864) 941-8105

14. The Children’s Center, Greenwood
Evidence-based
Home Visitation
The Children’s Pediatric
Center Medical Home
Services
Care
Behavioral Health
Services

15. Evidence-based Home Visitation
• Home visiting should not be delivered in isolation but as
part of the continuum of care and network of health
services for families with young children, beginning in
pregnancy.
• A continuum of evidence-based early childhood home
visitation provides the best fit for families and the most
cost-effective services.
• Our continuum includes Nurse-Family Partnership,
Healthy Families America/Parents as Teachers, and
Healthy Steps for Young Children.

16. System improvements
• Provision of a continuum of services to
provide the “best fit” for families.
• Increased access and decreased barriers to
services
• Seamless team approach utilizing medical
providers, home visitation providers and
behavioral health providers. Families hear
consistent messaging.

17. System improvements
• Shared use of electronic records for
communication
• Improved family identification, engagement
and retention.
• Use of a standardized screening and
assessment process prenatally and at birth
• Quality improvement across services using
PDSA format.
• Improved referral pathways to additional
community resources.

18. QTIP Example
Quality Indicator is number of children that
kept at least six well child visits from birth to
15 months.
• TCC – all children 55.2% met the indicator
• HS/HF children 72% met the indicator
• TCC – all children 77.6% with at least 5 visits
• HS/HF children 100 % with at least 5
visits

19. Healthy Steps expands traditional clinical
practice through the addition of Healthy Steps
Specialists (HSS) who provide services that
augment pediatric care by building parents’
knowledge about child development, and
their confidence in actively participating with
the pediatric team and in their child’s health
care.

20. Enhanced Well Child Care
Usually completed at the Well Child Visit. HSS
answer parents questions about developmental
issues or problems and referred to the physician
for medical issues.
Parents are given information on a variety of topics
and when needed, given ideas/exercises to
enhance developmental skills.

21. Healthy Steps parents receive a variety of handouts,
specific to the age of their child.
Pride Cards, in conjunction with the Greenville
Hospital System, are mailed directly to the parent
at key developmental stages through age 5.
LINK Letters are mailed to parents prior to the Well
Child visit. These inform the parent about what to
expect at the visit, give parenting tips and tools,
and act as a reminder of scheduled appointment.
These are given to age 3.

22. Links to community resources
Healthy Steps maintains a book of community
resources that includes information on child
care programs, libraries, as well as on
programs for substance abuse, counseling,
domestic stress, and housing.

23. Well Baby Plus: Collaborative Approach to
the Parent Child Relationship

24. Well Baby Plus intervention
• Group well child visits staffed by a private pediatric
practice (8 clinicians), who provided other medical
home services at their office. Group visits were
scheduled using the AAP periodicity schedule
• Utilized a school-based home visitation program
(“Parents as Teachers” curriculum). Home visitors
provided assistance with coordination, appointment
reminders, transportation and post visit reinforcement.
Home visitors attended the group well visits.
• Visits were provided on a school site where other
auxiliary services were present

25. Features of Well Baby Plus Evaluation
Group
• 119 Families offered
WB+
• 91 families enrolled
• 70 families still engaged
at 15 months of age
• 51 families completed
exit questionnaire
• Lived east of Battery
Creek

26. Comparison Group Features
• Received traditional
pediatric care within the
medical home
• Lived west of Battery
Creek
• Matched retrospectively
one to one with WB+
patients by maternal age,
marital status and SE
stress (Orr SES)

27. Methods
• Outcomes were assessed at or near the child’s
15-month visit by parental questionnaire and
review of the child’s medical records.
• Analysis used McNemars test for nominal data
and paired t-test for continuous data.

28. Completed all Well Child Visits
• Children in the WB+ 70%
intervention group 60%
(65%) were more likely 50%
than comparison group 40%
(37%) children to attend 30% WB+
all scheduled well-child 20% Control
visits 10%
0%
• ( p= 0.006) Completed
Well Baby
Visits

29. Immunization UTD as recorded in
Patient Chart
• 92% of WB+ children
95 were fully immunized
90
vs. 78% of comparison
children (p= 0.01)
85
WB+
80 Control
75
70

30. Trend towards Lower ER Utilization
• Well Baby Plus children
1.6 showed a trend towards
1.4 lower ED usage with an
1.2 average of 1.0 visit vs.
1 1.45 visits in the control
0.8
WB+ population (p=0.18)
Control
0.6 • Not statistically
0.4 significant
0.2
0

31. Well Baby Plus families were significantly more
likely to report their visits helped them become
better parents
100
90 • WB+ : 94% reported
80
70
that well child visits
60
WB+
were helpful
50
40 Control • Comparison: 76%
30 reported that well
20
10 child visits were
0 helpful
• p= 0.04

32. Family Spacing:
Well Baby Plus Mothers more likely to be
using birth control
30 • WB+: 25/41 using
25
birth control
(61%)
20
WB+
• Comparison:
15
Control 17/43 using birth
10
control (40%)
5
• p = 0.03
0
bc no bc

33. When child was 15 months, parents
recalled their clinician had discussed:
•WB+:
90
•P: Poisoning : 65% (p=0.003),
80
•D: Discip.:69% p<0.001),
70
60
•L: Literacy: 87% p=0.16) N:
Nutrition: 8%(p=0.17) T: Toi-
50
WB+ train:35%(p=0.01)
40
Control • Control Group:
30
• P: Poisoning: 41%, D:
20 Discipline: 31% L:Literacy: 75%
10 N: Nutrition: 78% T:Toilet-
0 Training 12%
P D L N T

34. Impact on Obesity?: Were Well Baby
Plus patients less like to be obese at
15 months of age?
25
• WB+
20 – weights> 90 percentile: 8%
– Average 50 percentile
15
WB+ • Control Group
– weights>90 percentile: 24%
10
Compari – Average 55 percentile
son – p=0.03
5
– This difference disappeared
0 when Weight vs. Height
Wt. Wt/Ht percentiles used (p=.3)
>90 >90

35. Conclusion
• South Carolina’s Children are failing to have
satisfactory development at alarming levels
• Home visitation’s time has come.
• Need to promote fidelity to proven home
visitation models
• Link home visitation to other services such as
the pediatric medical home
• Use the resources of the Affordable Care Act
and others to provide services